CEO SUMMARY: Canada has become one of the world’s hot spots for SARS. Concern about the unexpected number of hospital workers who contracted the disease triggered a halt to all but the most life-threatening patient care needs in many hospitals in Ontario. The manner in which this disease is transmitted is causing lab administrators in Toronto to rethink hospital infection control and microbiology activities.

MODERN AIR TRAVEL is demonstrating how swiftly an emerging disease like SARS (severe acute respiratory syndrome) can spread across the globe and challenge hospital-based laboratories.

Starting in mid-February in Hong Kong, a number of SARS-infected travelers carried the new disease to at least 20 different countries. By mid-March, serious outbreaks were recognized in China, Hong Kong, Vietnam, Singapore, and Canada.

SARS brought an added concern. SARS patients in Hong Kong and Toronto, Canada, once hospitalized, exposed a high number of hospital staff to the disease. Hospital workers were at significant risk if proper precautions were not taken.

In Toronto, health officials were quick to recognize this danger and responded immediately. “Hospitals in Toronto are under extraordinary restrictions,” stated Ene Underwood. “For the first two weeks of the outbreak, hospitals did only ‘life-threatening’ work.

“There’s now a gradual ramp-up of urgent work with most elective procedures and new referrals still on hold,” she added. “Entry to hospitals is restricted to staff and patients. Visitors are allowed in only if the death of their loved one is judged to be imminent. Almost daily, public health officials issue new guidelines in an effort to control the spread of SARS. ”

Underwood is President and CEO of Toronto Medical Laboratories, the 50/50 joint venture between University Health Network (which owns three hospitals) and MDS Inc. She is actively involved in coordinating how her laboratory responds to the daily changes in hospital procedures required by public health officials.

“We are still in the midst of an unfolding situation which has surprised many of us in the laboratory,” declared Underwood. “On one hand, SARS has validated that our laboratories were prepared to deal with a new disease. But the transmission dynamics of SARS presented us with new and unanticipated issues.”

Hospital Workers At Risk

One of the first discoveries about SARS was that the highly-transmit-table nature of SARS put healthcare workers on the front line of risk. “Scarborough Grace Hospital admitted Ontario’s first SARS patient on March 7,” said Underwood. “Within two weeks, 56 healthcare workers at Scarborough Grace Hospital were diagnosed with SARS and a total of 300 of the hospital’s 1,300 workers were exposed to the disease.

“According to statistics from the World Health Organization (WHO), the infection rate for people exposed to SARS is believed to be as high as 50%,” explained Underwood. “The mortality rate is around 4% to 5%. Exactly how the disease can be trans- mitted is still unknown and there is no diagnostic test. Because so many healthcare workers became infected in the two Toronto hospitals which treated SARS patients, quick action was required.”

Staff Put Under Quarantine

Health officials in the province were justifiably concerned that SARS could spread so rapidly among healthcare workers. The provincial health system took swift steps in response to the threat. “In late March, the entire staffs at Scarborough Grace Hospital and York Central Hospital were put under quarantine,” Underwood stated. “Also, anyone who visited either of those two facilities since March 16 is to be in quarantine. Quarantine is ten days without symptoms, as ten days is believed to be the incubation period for SARS.

“The changes here at Toronto General Hospital [Underwood’s base hospital] illustrate the full force of these new restrictions,” noted Underwood. “There are only two doors for entry. Patients and visitors go to one door. Hospital staff must enter through the other. At the door, staff is greeted by a staff member in gloves, mask, and goggles. Before entering, staff members must wash their hands with alcohol and complete a form daily which asks about recent travel to Asia, relevant symptoms, and similar questions. The staff member’s temperature is taken. Only after completing these steps can a staff member enter the hospital.

Patient Contact Procedures

“Within the hospital, staff has been required to wear masks. If seeing a patient, the staff member must wear gloves, a gown, goggles, and either an N-95 mask or PCM 2000,” added Underwood.

“It’s much the same story at our hospital,” observed Murray Treloar, M.D., Pathologist and Physician Leader of Laboratory and Genetic Services at Lakeridge Health, located in the Toronto suburb of Oshawa. “Entry to our hospital is limited and elective procedures are not taking place. We had a SARS patient in our emergency department and several nurses were exposed and were in quarantine at home.

“To keep SARS patients out of emergency departments, a SARS evaluation clinic was established at a location away from the hospital,” stated Treloar. “It operates from noon to 8 p.m. daily. SARS patients are not welcome in physicians’ offices now. So, if an individual thinks he or she might have SARS, most physicians are doing telephone triage and referring the patient to the SARS evaluation clinic.”

Both Treloar and Underwood said that, because elective surgeries and non-urgent procedures were not being done in their hospitals, their laboratories were testing significantly fewer specimens. However, testing on patients suspected of having SARS patients continues. Nasal swabs of such patients are sent to public health laboratories, but other testing continued to be done in the hospital labs.

Cross-Team Exposure

The SARS outbreak in Toronto is posing new questions about certain aspects of the way their laboratories are organized and operated. One example is in the relationship between the hospital infection control department and the microbiology laboratory.

THE DARK REPORT notes that one experience from the Toronto SARS outbreak may cause a rethinking of how infection control teams and microbiology labs interact. News accounts have made a big deal of the fact that microbiologist Allison Geer, M.D., who heads the infection control team at Mount Sinai Hospital, contracted SARS after visiting and treating the initial SARS patients before the outbreak was clearly understood. All six members of the Mount Sinai infection control team were quarantined and three members contracted SARS. Because of the close routine interaction between the infection control team and microbiology teams, there were initial concerns that a significant proportion of the microbiology department might be forced into quarantine at a critical time in the hospital’s response to the SARS outbreak.

Underwood Lists Lab Management Issues Triggered by SARS

2. Human resource issues result from restrictions that limit the number of people in hospitals. Significant numbers of lab staff were asked to stay home because of reduced test volumes and some lab staff are home under quarantine. Pay for those at home creates fairness issues with those in the lab working.

3. Continuity of business becomes a challenge. Ways must be developed to get vendors on site to service and repair laboratory equipment, as well as conduct normal lab business.

4. Transfusion medicine is affected by SARS. There are questions about the safety of the blood system and no effective screening for blood donors exists.

5. Microbiology–infection control relationships require assessment during potential infectious disease outbreaks. Personal interaction between the two groups may need to be restricted.

6. Legal exposure and risk of litigation must be recognized and addressed. The need to follow standards of care and fully document decisions is heightened, particularly when existing guidelines do not address the unique circumstances.

“At this point, the obvious implication is that there needs to be caution in how the microbiology and infection control staff interact,” said Underwood. “If the head of microbiology is also part of the infection control team, this may require a ‘Chinese wall’ to maintain separation.”

Impact On Regional Labs

The impact of city-wide restrictions on hospital activities and the quarantine of specific hospitals has revealed unanticipated complexities for regional lab organizations serving multiple sites. “Toronto Medical Laboratories is a regional laboratory and provides services to five acute care hospitals and four smaller specialty hospitals,” noted Underwood. “Because none of these facilities have stand-alone labs, restrictions on the movement of laboratory staff presented new challenges.

“For example, through the course of the outbreak, one hospital—a comprehensive cancer center—needed to continue providing relatively high levels of care. Our transfusion medicine service is provided through an on-site satellite lab with staff rotations from the larger consolidated lab located at another hospital site. Staff restrictions caused an increased workload for this satellite lab staff while some staff from the consolidated lab are at home with pay,” explained Underwood.

“It is a similar situation with pathology,” she added. “At our three teaching hospitals, the pathologists are consolidated at a single site and move to the other two sites to support quick sections. During this outbreak, to avoid moving pathologists among these sites, we’ve been forced to develop different work flow arrangements. We also had to make a decision about handling lab specimens between sites. Should SARS specimens be handled differently? The infection control team and the laboratory team studied that issue and decided that existing protocols provided adequate protection.

“Outside of the laboratory, the experience from this SARS outbreak has been to demonstrate that hospitals may need to have more negative pressure rooms to handle these types of patients,” added Underwood. “Around Toronto, hospital plant operations people have worked miracles to create negative pressure rooms literally overnight!”

THE DARK REPORT observes that the SARS outbreak in Toronto is changing daily. The facts reported here were accurate as of press time. The quarantine periods, which were started late in March, were initially set for ten days. Public health officials are watching to see if the number of new SARS cases declines. They are working to limit the outbreak to the third ring of transmission.

Labs Up To The Challenge

Toronto’s experience with severe acute respiratory syndrome (SARS) is revealing that the basic organization of hospital and laboratory services is performing well. But this outbreak has identified gaps in the organization of laboratory services which will need to be addressed by laboratories everywhere.

“Within the microbiology community, there is a strong view by people in the know that SARS is a useful dress rehearsal,” stated Underwood. “Just like the big earthquake is considered overdue for California, many infectious disease and microbiology specialists believe the next big influenza epidemic is overdue. SARS has provided compelling evidence of how quickly modern air travel can spread a new disease throughout the world.”